Admission to one of the state hospitals in West Virginia is gained
through a legal proceeding which is initiated on a county level. It was
hypothesized that involuntary psychiatric admission patterns from the
Sharpe Hospital catchment area do not have a direct correlation with
county population.

Methods: Sharpe Hospital admissions data for a one year period were
collected and demographic data from counties within the hospital
catchment area was obtained for comparison.

Results: Involuntary psychiatric admissions from the Sharpe
Hospital catchment area do not correlate directly with county
population, supporting the hypothesis that factors besides county
population explain differences in admission patterns. Socioeconomic
status, diversion of admissions to other hospitals and proximity to the
state hospital do not fully explain the differences.

Conclusion: Rates of admission were found to vary widely from
counties in the Sharpe Hospital catchment area. Local evaluation and
treatment variables and patient-specific factors such as diagnosis,
comorbid substance dependence, and psychiatric history warrant further
study to guide planning

There are at present, two inpatient acute care mental health
facilities operated by the West Virginia Dept of Health and Human
Resources with a total of 240 beds to serve the mentally ill population
of West Virginia. Each hospital has a designated catchment area with
corresponding Community Mental Health Centers. William R. Sharpe, Jr.
Hospital is a 150 bed facility located in Lewis County that serves 42 of
West Virginia's 55 counties. Mildred Mitchell Bateman Hospital in
Huntington has 90 beds and admits patients from 13 counties. All
admissions to the hospital are involuntary, either through civil
commitment or, in the case of forensic patients, through court order via
the judicial system. Civilly committed patients are admitted along
catchment area lines with few exceptions. Forensic patients from the
entire state are initially admitted to the forensic program at Sharpe.

The procedure by which an involuntary psychiatric admission occurs
is outlined in West Virginia Code Chapter 27 (1); in summary, the
process begins with application in the community, examination by a
licensed physician or mental health professional designated by the area
mental health center, and a mental hygiene hearing at the county level.
If "probable cause" is found that the person is mentally ill
or addicted and dangerous, then an order is entered for placement at a
mental health facility.

Since 2002 the census at Sharpe Hospital has nearly consistently
been above its designed capacity of 150 patients. When this is the case,
attempts are made to divert admissions to non-DHHR inpatient facilities
willing to accept involuntary patients. The inpatient stay for these
patients is funded by the state. It was evident from casual observation
at Sharpe Hospital that more admissions came from some counties than
others. The authors chose to quantify these observations and to study
other variables related to admissions in an attempt to determine current
admission patterns and to consider best practices to respond on a
hospital level. However, since each patient is admitted through a
county-level process, analysis of Sharpe Hospital admission patterns in
light of variables within the catchment area counties would be important
for state level planning for psychiatric treatment. Various
patient-specific (e.g. poverty and diagnosis) and external (e.g.
population and proximity to hospital) factors have been shown to
positively predict rates of psychiatric admission (2) and recent data
reveals a trend toward increasing forensic patient populations. (3)
Additionally, admission to a public mental health facility and
involuntary admission both have been associated with greater severity of
illness (4) and low socioeconomic status and service quality at the
local level. (5) Our initial analysis considered Sharpe Hospital
catchment area demographic data to test the hypothesis that the number
of involuntary admissions at Sharpe from each county does not directly
correlate with the population of the county but is also impacted by
other variables; therefore, rates are not constant across the catchment
area.

Methods

The research project was approved by the William R. Sharpe, Jr.
Hospital Research Committee. The database of information relating to
admission numbers, counties from which referrals came, legal status, and
diversions to other hospitals was obtained from archival sources, with
the cooperation of Sharpe's Health Information Management and
Admissions personnel. All admissions from April 1, 2007 through March
31, 2008 were studied. The data was transferred into S.P.S.S.
(Statistical Package for the Social Sciences, Version 10, 2004, SPSS
Inc.) and analyzed. Data was subsequently entered into Microsoft Office
Excel 2003 (Copyright 1985-2003 Microsoft Corporation) for calculation
of rates, rank sorting and graphing. Population data was obtained from
the United States Census Bureau (6) for calculation of rates per 100,000
population in each county.

Results

During the year of this study, there were 840 admissions to Sharpe
Hospital. Overall, 794, or 94.5%, of all involuntary admissions were
from within Sharpe's catchment area, 34, or 4%, were from
Bateman's catchment area and 12, or 1.4%, were from out of state.
Seventy-three, or 8.7%, of the 840 admissions were court-ordered
forensic patients, with 22, or 30.1%, of these coming from outside of
Sharpe's catchment area.

Our hypothesis that involuntary hospitalizations do not directly
correlate with county population was supported by the data. Rates of
admission to Sharpe range from 0 to 168 with a mean of 69. Wood County,
with the third largest population, had the highest rate of admission and
admitted 145 (17.3%) of the overall total, more than double that of any
other county. Taylor, Calhoun, Tyler and Pendleton Counties follow Wood
County in rate of admissions; but in that their populations are small,
their actual impact on Sharpe admissions is limited. In contrast to Wood
County, the most populous county in the Sharpe catchment area, Berkeley
County, had only 18 admissions, ranking it 37 out the 42 counties in
rate.

The number of patients from Sharpe's catchment area diverted
to other facilities and not admitted to the state hospital was also
considered as a potentially confounding variable so this data was
analyzed. There were ten hospitals that admitted patients under probable
cause status as diversions; more patients were actually diverted than
admitted to the state hospital. Most of the diversion hospitals accept
primarily (or almost exclusively in some cases) patients from their own
or nearby counties. As can be seen from Table 1, several counties
diverted more patients than they admitted; there are diversion hospitals
in these counties or very nearby.

The county rates of total involuntary admissions either to Sharpe
or a diversion hospital were calculated as these rates actually reflect
state-funded psychiatric admissions from the catchment area. These rates
differ substantially for some counties from the rates of admission to
Sharpe Hospital and range from 0 to 568. For example, Ohio County, the
9th most populous county, located in the Northern Panhandle, had 217
diversions with only 35 Sharpe Hospital admissions and had the highest
rate of diversion as well as total involuntary admission in the
catchment area. It should be noted that the local mental health center
is located adjacent to a general hospital with an inpatient psychiatric
unit; the majority of commitments from this catchment area were admitted
to this unit. The three very populous counties in the Eastern Panhandle,
Morgan, Jefferson, and Berkeley, had the lowest total rates of
admission.

Graphical representation by scatterplot of the relationship between
both Sharpe admissions and total involuntary admissions (Chart 1) tends
to be positive overall; however, covariance is not linear over the
entire range of values, the small number of admissions from some
counties and the broad range of rates preclude statistically valid
correlation analyses.

To further explore the disparity between admission numbers from
various counties in Sharpe's catchment area, the United States
Census Bureau data regarding poverty level and estimated household
income for 2007 was also obtained7. Rates of poverty were calculated
based on population for the 42 counties in the catchment area. To assess
the relationship between involuntary admission rates, poverty rates, and
median income, correlation coefficients were calculated. This
relationship is graphically illustrated in Charts 2 and 3. The
correlations between involuntary admission rates and median income (r=
-0.10) and rate of poverty (r=0.12) were reflective of no relationship.

[GRAPHIC 1 OMITTED]

Proximity to the state hospital also appears to have a limited
correlation with admission rates to Sharpe Hospital. Lewis County, the
location of Sharpe Hospital, ranked sixth in rate. Wood County, first in
rate, is approximately an hour and three quarters drive from Sharpe.
Most of the counties with low rates of admission to Sharpe (e.g. the
Eastern Panhandle) are at a considerable distance from Sharpe, but
Spencer in Roane County is only fifty miles from Weston and is second to
last in rate of admissions. Though all adult patients in West Virginia
involuntarily hospitalized through the mental hygiene process come to
the state hospital or an in-state diversion hospital, it is possible
that lower rates are found, especially in border counties, due to
patient evaluation and hospitalization at an out of state facility.

[GRAPHIC 2 OMITTED]

[GRAPHIC 3 OMITTED]

Discussion

The finding that variation in admission rates across the catchment
area is not explained by differences in population, socioeconomic
status, or proximity to the state hospital is consistent with prior
studies. (5) Local mental health center staff may reasonably make the
case for commitment with the mental hygiene commissioner if a patient is
poor with inadequate housing, living in a remote area with limited
access to outpatient treatment, and has no other access to
hospitalization due to having no payer source. Study of individual
characteristics of patients referred for evaluation at West Virginia
mental health centers and subsequently involuntarily hospitalized may
elucidate some correlative factors. It has certainly been demonstrated
that the needs of remote rural patient populations pose unique
challenges when attempts are made to provide ethical and adequate mental
health care. (8) However, there has also been evidence to indicate that
non-clinical, non-patient factors are even more likely to play
significant role in involuntary treatment decisions. (9) Lorant's
Belgian study determined that lack of a less restrictive alternative was
the most crucial factor driving the decision for involuntary treatment;
more than patient refusal, dangerousness, diagnosis, housing status, or
other factors. (10) His findings are consistent with studies done in the
United States. (11,12) In Lorant's study, more than half of those
referred for evaluation were not committed. All of the evaluations were
performed by psychiatrists at a teaching hospital psychiatric emergency
room, a notable difference which may have impacted outcomes (13); in
West Virginia, a mental health center nonphysician is usually the
evaluator. Medical clearance, if it occurs, is done after the hearing.
If the symptoms warranting commitment are found to be secondary to a
medical etiology or intoxication, the patient may still be involuntarily
psychiatrically hospitalized since probable cause has already been
found, unless a medical condition, once discovered, justifies acute
medical hospitalization. Our study was limited to patients who were
involuntarily hospitalized; so the rate of patients evaluated and not
committed in each county is unknown. We are currently collecting data
for further study on patients admitted to Sharpe Hospital with medical
conditions necessitating transfer to an acute care medical hospital.

The level and type of outpatient services, which were not examined
for this study, vary greatly between mental health centers and may
contribute to the differences in involuntary admission rates. Local
operational norms, level of professional accountability for assessment
decisions, organizational culture and support in decisions to care for a
patient in the community, perceptions of conditions at the state
hospital, and whether or not involuntary hospitalization is considered a
"last resort" option all have been shown to influence the
compulsory admission threshold. (9,14)

[ILLUSTRATION OMITTED]

Similarly, the impact of state-financed diversion admissions on
readiness to petition for involuntary treatment is unknown. In theory,
it is beneficial to the patient and their family, the diversion hospital
with open bed space, and the Sheriff's Department transporting
personnel to keep the treatment local. For a patient who wants and needs
treatment but has limited resources for receiving inpatient or
outpatient services, it may seem more justifiable to make the case for
involuntary treatment even when a patient is actually willing to receive
it and may have presented to the diverting hospital requesting it. As
legislative decisions are made to address overcrowding at state
psychiatric facilities, the following issues warrant consideration: data
suggests a positive correlation between rates of compulsory admission
and number of psychiatric beds (13), transfers of patients to state
funded treatment may be economically-motivated, especially if there is
no incentive to provide treatment in another setting (15), and
increasing inpatient beds without developing comprehensive outpatient
treatment (which is also costly) to care for discharged patients
(16,17), may only serve to increase state hospital use by those who are
already high users (18) or the number of long stay patients awaiting an
appropriate placement.

Conclusion

Rates of admission to Sharpe Hospital and overall involuntary
admission rates vary by county in the Sharpe Hospital catchment area.
Further study of local evaluation and treatment variables as well as
patient specific factors such as diagnosis, co morbid substance
dependence, and psychiatric hospitalization history and length of stay
is warranted to guide mental health planning and funding allocation.